JACLOCUMS
Candidate Application Form
1
Jac Locums Limited, 105 Eastern Way, Letchworth Garden City,
Hertfordshire, SG6 4PG, Phone: 01462338206, Fax 01462338206
Company Reg No. 08171798
Please read this form carefully before completing all sections to ensure you provide all the required
information. This form can be completed both manually and electronically. PLEASE PRINT IN BLOCK
LETTERS USING BLACK INK (if completing manually). Post to JACLOCUMS at the address on the bottom
of the page. Electronically - please DOWNLOAD and fill in then email to: recruitment@jaclocums.com.
PERSONAL DETAILS
Position Applied for
Mr/Mrs/Miss/Ms
First Names
Address
Surname
Correspondence Address (if different)
Post Code
Telephone
Maiden Names
Post Code
Home
Work
Mobile
Email
Date of Birth
Nationality
Age
National Insurance no.
NMC no: (if applicable)
Own
Transport
NMC expiry date
Next of Kin
Address(if different)
Telephone
Home:
Work:
Mobile:
Email:
2
Jac Locums Limited, 105 Eastern Way, Letchworth Garden City,
Hertfordshire, SG6 4PG, Phone: 01462338206, Fax 01462338206
Company Reg No. 08171798
PRIMARY EDUCATION
School name
City / Country
Dates
Outcome/Results
Secondary Education
School name
City / Country
Dates
Outcome/Results
Higher Education
College /University name
City / Country
Dates
Outcome/Results
Organisation
Professional Membership and Registration (e.g. NMC)
Registration
No.
Valid from
EMPLOYMENT HISTORY
(NOTE: if you were looking after children or self-employed, please state)
Current/Most recent job
Name of organisation
Dates of employment
Reason for leaving
Salary
Per week/month/hour
3
Jac Locums Limited, 105 Eastern Way, Letchworth Garden City,
Hertfordshire, SG6 4PG, Phone: 01462338206, Fax 01462338206
Company Reg No. 08171798
Expiry date
PREVIOUS EMPLOYMENT
(Please begin with the most recent first-Include work you did through agencies)
Employer’s name
and address
Employment dates
From
To
Job title/
post
Band/Grade
Reason for leaving
Have you ever been dismissed from employment, faced disciplinary action
Or awaiting disciplinary hearing/investigation?

If you answered yes to above question please give more details in this section:
4
Jac Locums Limited, 105 Eastern Way, Letchworth Garden City,
Hertfordshire, SG6 4PG, Phone: 01462338206, Fax 01462338206
Company Reg No. 08171798
YES
NO
REFERENCES
1.
Please give names and addresses of two referees, at least one reference must be your present or last
employer, who is in a position to comment on your work experience and suitability for the post to which you
have applied. This must be a Manager/ Supervisor.
2.
If you have not been employed and/or never worked or you have not worked for some time you could
provide the name of a head teacher or course tutor, supervisor or coordinators of school and college work
experience placements and/or any voluntary work.
3.
Please do not give names of family members or friends. Note that the references you provide should have
direct relationship with your work and/or life history.
Referee 1
Name
Position
Relationship
How long known to you
Work Address
Referee 2
Name
Position
Relationship
How long known to
you
Work Address
Post Code
Phone
Mobile
Email:
Post Code
Phone
Mobile
Email
Please note that references will be taken up prior to commencing work. JACLOCUMS expects you to have the
experience and qualifications that you state in your application.
MEDICAL HISTORY
YES
NO
YES
NO
Details(Please give dates)
Have you ever been treated at a hospital for serious
illness or surgery? Please answer YES/ NO
Are you a registered disabled person? YES/ NO
What is the date of your last chest x-ray?
How much time have you lost from work due to
Illness in the last five years? (Please provide details)
Have you ever suffered from any of the following?
Heart/Circulatory Illness/Hypertension
Diabetes
Asthma/Hay fever
Bronchitis/Pneumonia/Pleurisy
Tuberculosis
5
Jac Locums Limited, 105 Eastern Way, Letchworth Garden City,
Hertfordshire, SG6 4PG, Phone: 01462338206, Fax 01462338206
Company Reg No. 08171798
MEDICAL HISTORY -CONTINUED
Epilepsy/Frequent Fainting Attacks
Headaches/Migraine
Psychiatric Illness/Anxiety/Depression
Dermatitis, Skin Sensitivity (Allergies) Psoriasis/Eczema
Back Injury/Back Problems or Back Pains
Recurrent Infections e.g. Sore Throats/Ear Infections
Hepatitis/Jaundice
Are you receiving Medicines, Pills or Tables from a
Doctor or on Prescription?
Do you have any other physical disabilities other than
those listed above that could affect your ability to carry
out your assignment?
YES
NO
Details
11. Rehabilitation of Offenders Act
As a general rule, no-one need answer questions about spent convictions. However this
general rule does not apply to specified professions, employments and occupations. By virtue
of the Rehabilitation of Offenders Act 1974 (Exceptions) (Amendment) Orders, the exemption
rule does not apply to:
a) any employment or other work which is concerned with the provision of health
services and which is of such a kind as to enable the holder of that employment or the
person engaged in that work to have access to persons in receipt of such services in
the course of his normal duties, or
b) any employment or other work which is concerned with the provision of care services
to vulnerable adults and which is of such a kind as to enable the holder of that
employment or the person engaged in that work to have access to vulnerable adults in
receipt of such services in the course of his normal duties
One or both of the above apply to work with the Agency, and covers all occupations.
You are therefore requested to provide details of all convictions, including those which would
otherwise be considered as “spent”. All employment applications will be considered carefully,
and the disclosure of a conviction does not imply that this employment application will be
rejected.
Records will be checked via the Criminal Records Bureau procedures
I have no convictions

I have convictions (see Note below)

Please  as appropriate
Note
(To protect the confidentiality of this information, please detail convictions on a separate sheet of
paper. Place it in a sealed envelope with your name clearly visible, and headed “Private and Confidential
– Criminal Convictions” and attach this to your completed Application Form)
6
Jac Locums Limited, 105 Eastern Way, Letchworth Garden City,
Hertfordshire, SG6 4PG, Phone: 01462338206, Fax 01462338206
Company Reg No. 08171798
Criminal Records – Disclosure Certificate
The Criminal Records Bureau (CRB) has issued a Code of Practice regarding Disclosure
Information, a copy of which is available upon request. A Disclosure Certificate (standard or
enhanced) will be requested from the CRB which will detail all convictions, including those
which would otherwise be “spent”, as well as details of cautions, reprimands or final warnings.
You will be advised of the type of certificate being requested and asked to give your approval
to this application. The Disclosure Certificate will only be requested in the event that you are
successful in your application for employment.
Asylum and Immigration Act 1996
Under Section 8 of the Asylum and Immigration Act 1996 it is a criminal offence to employ a
person aged 16 or over who is subject to immigration control unless:

That person has current and valid permission to be in the United Kingdom and that
permission does not prevent him or her from taking the job in question; or


The person comes into a category specified by the Home Secretary where such
employment is allowed
Any employment offered will be subject to the successful applicant producing appropriate
evidence that the Asylum and Immigration Act is not being contravened.
Are you eligible to work in the UK? Yes

No

Please  as appropriate
Personal Declaration
I declare that to the best of my knowledge the above information, and that submitted
in any accompanying documents, is correct, and

I give permission for any enquiries that need to be made to confirm such matters as
qualifications. , experience and dates of employment and for the release by other people
or organisations of such information as may be necessary for that purpose.

I give permission for the processing of the personal data contained in this form for
employment purposes
I understand that any false or misleading information could result in my dismissal.

Signed
Date
7
Jac Locums Limited, 105 Eastern Way, Letchworth Garden City,
Hertfordshire, SG6 4PG, Phone: 01462338206, Fax 01462338206
Company Reg No. 08171798
Equal Opportunities Monitoring Form
JAC LOCUMS LIMITED operates a policy of Equal Opportunities: therefore, we need to be able to
check that decisions are not influenced by unfair or unlawful discrimination. To help use to do this
we would be grateful if you could complete this short questionnaire.
Your answers will be treated in full confidence and will be used only for statistical purposes.
What is your ethnic group?
Choose ONE section from A to E, and then circle the appropriate box to indicate your cultural
background.
A White
British
Irish
Any other White background, please write in here.
B Mixed
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed background, please write in here.
C Asian or Asian British
Indian
Pakistani
Bangladeshi
Any other Asian background, please write in here.
D Black or Black British
Caribbean
African
Any other Black background, please write in here.
E Chinese of other ethnic group
Chinese
Any other, please write here.
SEX
Female
Male
DISABILITY
Applicants with disabilities will be invited for interview if the essential job criteria are met. Do you
consider yourself to be a person with a disability as described by the disability discrimination act 1995?
i.e. do you consider yourself to be someone who has a physical or mental impairment which has a
substantial and long term adverse effect on your ability to carry out normal day to day activities
Yes
No
8
Jac Locums Limited, 105 Eastern Way, Letchworth Garden City,
Hertfordshire, SG6 4PG, Phone: 01462338206, Fax 01462338206
Company Reg No. 08171798
10. Confidentiality declaration
Registration implies acceptance of our code of confidentiality.
In the course of your duties you may have access to confidential information about your clients.
On no account must information relating to identifiable client be divulged to anyone other than
the manager of the agency. You should not disclose ANY information to your family, friends or
neighbours.
If you are worried by any information you have obtained and consider that you should talk
about it to someone else MAKE AN APPOINTMENT TO SPEAK IN PRIVATE TO YOUR MANAGER.
Failure to observe these rules will be regarded as serious misconduct which could result in
removal from the agency register.
I have read and I understand the above and I agree to abide by the contents therein.
Signed
Date
9
Jac Locums Limited, 105 Eastern Way, Letchworth Garden City,
Hertfordshire, SG6 4PG, Phone: 01462338206, Fax 01462338206
Company Reg No. 08171798
For Office Use Only
Initials
Date Application received
Date Application acknowledged
Initial Decision
Date Applicant informed
Date(s) of Interview
Decision
10
Jac Locums Limited, 105 Eastern Way, Letchworth Garden City,
Hertfordshire, SG6 4PG, Phone: 01462338206, Fax 01462338206
Company Reg No. 08171798
Notes
11
Jac Locums Limited, 105 Eastern Way, Letchworth Garden City,
Hertfordshire, SG6 4PG, Phone: 01462338206, Fax 01462338206
Company Reg No. 08171798